Coronary Artery Calcium versus Biomarkers: Which Better Predicts Cardiovascular Events?

Editor’s Note:  Richard A. Ferraro, MD, is a cardiology fellow at the Johns Hopkins Heart and Vascular Institute. He is also a guest correspondent for the CardioNerds, a DocWire News content partner, and the producer of the CardioNerds podcast. Read more from the CardioNerds here. Follow Dr. Ferraro on Twitter @RichardAFerraro

Coronary artery calcium (CAC) and biomarkers have been of interest in recent years as predictors of downstream cardiovascular events. While both certainly hold important roles, which of the two is a better predictor? At the American Society for Preventive Cardiology (ASPC), two giants of their respective fields took to the virtual stage to debate just this question.

The debate itself was moderated by ASPC board member Dr. Ann Marie Navar from the University of Texas – Southwestern. In defense of coronary artery calcium was Dr. Khurram Nasir from Houston Methodist Hospital, Chief of the Division of Cardiovascular Prevention and Wellness.  Speaking for biomarkers was Dr. Christie Ballantyne of the Baylor College of Medicine, Chief of Cardiology and Cardiovascular Research.

Dr. Nasir began with an important discussion on risk stratification.  In terms of atherosclerotic risk, “calcium score has been established as the front-runner as there is no better marker that I know predicts those who are at the highest risk among those without established cardiovascular disease.” Conversely, Dr. Nasir also noted that calcium scoring may “de-risk” some patients, thus allowing for better overall prognostication. He did acknowledge, however, that CAC zero does not equate to zero risk. Dr. Nasir concluded pointedly, questioning if it was the time to leave behind the dogma of legacy tools and embrace technology and the big data tools of the future to best risk stratify.

Dr. Ballantyne remarked that our goal should not just be the prevention of atherosclerosis, but accompanying comorbidities such as diabetes and heart failure. This is where biomarkers come in. He presented a case to illustrate – a young patient with hypertension, elevated LDL, and a high Lp(a) may have a CAC score of zero and yet be at tremendous lifetime risk. He further noted that the most common event after visit 5 of the longitudinal ARIC study was not an atherosclerotic event, but heart failure, an outcome not predicted by CAC alone. He concluded by stating that while CAC is a useful tool for atherosclerotic disease risk, it does not have the predictive value required for the development and prevention of related disease states. Biomarkers, therefore, are the superior instrument in this regard.

Does CAC or biomarkers win the day as the better prognostic tool in cardiovascular prevention? Where do you side in the debate?